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Does primary indication for tonsillectomy influence post-tonsillectomy haemorrhage rates in children?
International Journal of Pediatric Otorhinolaryngology 79 (2015) 246–250
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Does primary indication for tonsillectomy influence post-tonsillectomy haemorrhage rates in children? P. Achar *, R.K. Sharma, S. De, A.J. Donne Alder Hey Children’s Hospital, Eaton Road, Liverpool L12 2AP, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 October 2014 Received in revised form 14 December 2014 Accepted 15 December 2014 Available online 23 December 2014
Introduction: A significant risk in tonsillectomy that causes concern to surgeon and patient is posttonsillectomy bleed. Secondary haemorrhage is mainly post-operative bleed presenting at or 24 h after surgery. Classical teaching indicates infection as the cause. There are not enough published data to evaluate the post-tonsillectomy bleed rates in patients operated for obstructive sleep apnoea versus recurrent tonsillitis. We suspected secondary bleed rates to be higher in patients with recurrent tonsillitis. Methods: A retrospective review of case-notes of patients presenting to Accident & Emergency department within 4 weeks of tonsillectomy or adeno-tonsillectomy was performed. 568 patients presented with post-operative complications over the 5-year period 2008–2013. Of these, 222 presented with post-operative secondary bleed. Electronic case records were used to identify indication of operation and matched with coding data. These coded data were also used to identify number of operations and primary indications over the 5-year period. Results: The proportion of OSA patients receiving tonsillectomy or adenotonsillectomy surgery increased over the 5-year period. Secondary haemorrhage rate for recurrent tonsillitis surgery was around 4.9% and for OSA surgery was around 15.6%. Comparison of recurrent tonsillitis against OSA for post-operative bleed showed a relative risk of 0.31 (CI 0.24–0.41). The incidence of bleeding mirrored primary indication for each year. Conclusion: The bleed rate for OSA was unexpectedly higher than for recurrent tonsillitis. The primary indication for tonsillectomy affects secondary bleeding rate. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Secondary haemorrhage Paediatric tonsillectomy Indications for tonsillectomy
1. Introduction The ENT UK position paper (2009) on Indications for tonsillectomy showed a decline in the total number of tonsillectomies over the last few decades. This is one of the commonest operations performed in children. However, there is a rise in the recognition of obstructive sleep apnoea (OSA) and sleep disordered breathing in children and subsequent rise in adeno-tonsillectomy for this indication [1,2]. Haemorrhage is one of the most common complication following tonsillectomy [3] and the most significant one. Several studies have reported correlation of post-tonsillectomy bleed rates in children versus the dissection approach and use of various instruments [4–9]. But there are not many studies looking into correlation of secondary post tonsillectomy haemorrhage and
* Corresponding author at: Holme Avenue, Wigan WN1 2EH, United Kingdom. Tel.: +44 1942820430. E-mail address: [email protected] (P. Achar). http://dx.doi.org/10.1016/j.ijporl.2014.12.022 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
the primary indication for the tonsillectomy. Secondary haemorrhage is defined as haemorrhage following 24 h of injury or operation [9] and is postulated to be due to infection perioperatively [10–13]. We hypothesized that children operated on for recurrent tonsillitis are more prone to infections and hence more likely to present with secondary haemorrhage. To investigate this, we performed a case note review on all patients presenting to Accident & Emergency (A&E) with secondary bleed in a paediatric tertiary referral unit in the North-West of England. 2. Methods A retrospective baseline audit of all patients presenting to A&E within 4 weeks of tonsillectomy and adeno-tonsillectomy between January 2008 and December 2012 was performed. This audit was registered with the Trust audit department. A&E notes of all these patients were screened to identify those who presented with secondary haemorrhage. ENT clinic letters of patients presenting with post-op bleeding were read closely to identify the primary
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indication and any co-morbidities. Standard hospital coded data were used to identify the total number of operations (tonsillectomy and adenotonsillectomy) performed in the same time period and the primary indication for the operation. These count data enabled calculation of the incidence of post-operative secondary bleed in children operated for primary indication of recurrent tonsillitis and likewise for OSA. Incidences were converted to relative risks (RR). 3. Results 3527 tonsillectomies and adeno-tonsillectomies were performed over the 5-year period between January 2008 and December 2012. Of these 417 (12%) were operated for obstructive sleep apnoea and 3079 (87%) were operated for recurrent tonsillitis. 31 (1%) were operated for other reasons. In this department there has been a decline in the total number of tonsillectomies over the last decade, however there is a slow rise in the number, hence the proportion, of cases operated on for obstructive sleep apnoea (Fig. 1). These data do not distinguish between case incidence and tendency to operate as explanation. 568 (16%) patients presented to our A&E with post-operative complications within the first 4 weeks. Of these, 222 (6%) were for secondary bleed, presenting between 2 and 27 days post-op. The median day of presentation with post-op bleed was on day 7. The remaining 346 cases presented in A&E for various reasons which include inadequate pain relief with poor oral intake; fever; and nausea and/or vomiting. The chief primary indication of the 222 post-op bleed presentations was 150 recurrent tonsillitis (150), with 65 OSA and 7 other (choking on food due to large tonsils, halitosis, asymmetrical tonsils for diagnosis) (Fig. 2). In the OSA group of patients, 28 were pure OSA with no history of tonsillitis or sore throats and 37 had OSA with a few episodes of tonsillitis (not fulfilling SIGN guidelines; the primary indication was therefore OSA). The median age of post-op bleed patients operated on for OSA was 5 years and 1 month and modal distribution showed highest bleed rates among 4–5 year olds (Fig. 3). Age of post-op bleed patients operated for OSA ranged from 1 year 1 month to 15 years. In the group of patients operated for recurrent tonsillitis, the median age was 10 year and 7 months and the age ranged from 2 years and 2 months to 16 years and 5 months. There was a bimodal distribution of age of patients presenting with post-op bleed in the tonsillitis group, with peaks at 6–7 year and in teenage years (Fig. 4). Comparing the mean age for the two groups, the OSA group of children (mean = 5.5 years) was almost half the mean age of the post-tonsillectomy group (mean = 9.7 years) and this difference was statistically significant (P = 0.02). The female-to-male ratio in post-operative bleed in OSA group of patients was 22:43 and in recurrent tonsillitis group of patients was 91:49. We subdivided our bleeds through 3 grades
Fig. 1. Annual caseload statistics over 5 year.
Fig. 2. Primary indication for operation in patients presenting with post-operative bleeding.
equivalent to Windfuhr and Seehafer’s [14] classification of post-op bleed severity; grade I = mild oral bleed, not requiring treatment; grade II = moderate oral bleed needing some topical treatment (for e.g. hydrogen peroxide gargles/adrenaline swab
Fig. 3. Age of patients presenting with post-op bleeds in OSA group.
Fig. 4. Age of patients presenting with post op bleeds in tonsillitis group.
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Fig. 5. Severity of post-operative bleed in recurrent tonsillitis versus OSA.
Fig. 7. Annual secondary post-operative bleed rate in patients operated on for tonsillitis.
application to stop the bleed); grade III = significant bleed needing return to theatre for arrest of bleed and/or needing blood transfusions to replace acute blood loss. Fig. 5 shows the break down of the children under each indication for mild, moderate and severe bleeds. Given that we perform an average of 12% of operations for OSA, a significant proportion of OSA patients presented with mild, moderate and severe bleed as compared to tonsillitis group. None of our patients needed ligation of external carotid artery (grade IV) and there were no post-op bleed related deaths (grade V) during the study period.
On comparing annual haemorrhage rate over the 5-year period for OSA and recurrent tonsillitis, we found the haemorrhage rate for OSA was consistently higher than for tonsillitis group of patients. The 5-year cumulative bleed rate for OSA was 15.6% as compared to 4.9% for tonsillitis. OSA patients presented with bleed more often than tonsillitis patients, consistently every year (Figs. 7 and 8). We calculated the relative risk to compare the probability of bleeds in tonsillitis versus OSA. Tonsillitis patients were 69% less at risk. The confidence interval (0.24, 0.41) excludes 1.0, which remains under 1 in both extremes suggesting significance (P < 0.05).
If we now exclude all those patients in the OSA group who had only very few episodes of tonsillitis, we have 28 patients who were operated for pure OSA who presented with post-op bleed. The annual haemorrhage rate in pure OSA was again consistently higher than for tonsillitis group, except in 2012. The 5-year cumulative bleed rate in pure OSA group was 7.4% (Fig. 6). A relative risk calculation showed that the OSA group are 1.51 times more likely to present with bleed as compared to the tonsillitis group. The confidence interval for this relative risk is (1.08, 2.12). This does not contain 1.00 so is statistically significant (P < 0.05). We also looked at the operative techniques used in Alder Hey. The tonsillectomy technique is mainly surgeon dependent and includes: cold steel dissection with ties and bipolar diathermy for haemostasis; coblation dissection and haemostasis; and bipolar dissection with ties and bipolar diathermy for haemostasis. Looking at the OSA group who presented with secondary bleeds, 24% had cold steel, 45% had coblation and 23% had bipolar dissection. Clearly, again, taking into consideration the fact that 12% of patients were operated for OSA, the bleed rates for OSA group of patients was consistently higher for each operative technique. We do not have the total number of patients operated on by each technique over the 5-year period, hence could not perform an interaction test between the indication and technique to look for any statistical significance for the above statement.
Fig. 6. Annual secondary post-operative bleed rate in patients operated on for OSA.
Fig. 8. Annual secondary post-operative bleed rate in patients operated on for OSA and had few episodes of tonsillitis.
3.1. Annual haemorrhage rate over 5-year period
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4. Discussion The national prospective tonsillectomy audit [9] has summarised that the risk of haemorrhage increases with age and also it is higher with hot surgical techniques (diathermy & coblation tools) as compared to cold steel dissection and use of ties. The national audit has also looked into the primary indication of operation and its associated risk, and shown that post-op bleed rate is lower in cases operated for pharyngeal obstruction as compared to recurrent tonsillitis. However there is no data given on the age group of this population presenting with pharyngeal obstruction. Also, in the national audit, only patients registered and consenting to participate in this audit were considered. Hence, there could be a group of patients who presented with postoperative bleed and not recorded in this audit, which can alter the study result. In our study, we included all children who presented with post-op bleed to the hospital accident and emergency department. Re-attenders to A&E can be a selective population excluding all those who had minor bleeds at home that settled spontaneously (this group of patients should not have an impact on our results, as the bleed was probably self-limiting, hence the nonattendance); and those who might have presented to other hospital A&E. Alder Hey Children’s hospital is a major tertiary referral unit in the North West region in England, and we receive children with post-tonsillectomy bleed from other accident and emergency units within the region for further management. This is irrespective of where the child received the first operation. On this basis, it is highly unlikely that any significant proportion of children operated in Alder Hey and presenting with bleed would be missed from our sample. A recent study by Perkins et al. [15] looking into the risk of posttonsillectomy haemorrhage by clinical diagnosis has shown increased incidence of haemorrhage in tonsillitis group of patients as compared to OSA. This study has included incidence of both primary and secondary haemorrhage. There is a possible confounding factor of ease of surgical technique in OSA group with less surgical trauma increasing likelihood of primary haemorrhage in the technically more traumatic surgery for the tonsillitis group due to scarring. It is believed that OSA patients have increased antifibrinolytic state, which could be protective from post op bleeds in this group of patients. Akin et al. [16] however, postulated a slight higher incidence of post-op bleed in their sleep apnoea group of patients as being related to their age. This was again a mixed population including children and young adults. There have been several other independent case series and randomised trials [17–20] looking into the correlation of tonsillectomy technique and post-op bleed rates. Other studies have looked into correlation of post-operative prophylactic antibiotics and secondary haemorrhage rate [21–23] finding no particular use of antibiotics in preventing post-op secondary haemorrhage. The Cochrane review by Dhiwaker et al. [21] has concluded that there is no evidence to suggest a role of antibiotics in reducing post-tonsillectomy morbidity. Obstructive sleep apnoea and sleep disordered breathing are conditions that are being increasingly recognised in the relatively younger population. In Alder Hey, we have seen a steady rise in this subgroup of children being offered tonsillectomy/adeno-tonsillectomy to improve the oro-nasal airway in the last decade. The diagnosis of OSA is done on clinical grounds and overnight pulseoxymetry results. The post-operative care pathway for these patients is similar to the ones operated on for recurrent tonsillitis except for the patients with severe obstructive sleep apnoea who are monitored overnight in the high-dependency unit or in the ENT unit with one-to-two nursing. These children are administered oxygen by face-mask overnight if desaturations are not selfcorrecting and CPAP is available if necessary. Their stay may be
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prolonged by one or two nights depending on the recovery period, awaiting oxygen free night sleeps. Whether this difference in the post-operative care pathway has any correlation with our finding of increased post-operative bleed in OSA group of patients is not clear. Considering the patient demographics, the group of children operated on for OSA is younger than those operated on for recurrent tonsillitis, as expected. Previous studies have shown that older children are more likely to present with secondary haemorrhage than younger children [24–26]. In our study, we have seen younger children presenting with secondary bleeds. 5. Limitations Our study is a retrospective one, setting limitations in the data variables available and in the limited means of controlling for confounders. We have sampled only those patients who presented in A&E in our hospital despite the initial catchment area being wider. There may be some patients who presented with post-op bleeds at other A&E departments and hence not in our records. This population mobility is likely to be small and at random, and hence not bearing a true impact on our results. It is more likely that the patients from far away would have the OSA indication, as Alder Hey is the tertiary referral centre for surgical management of OSA. This would make the differences even more obvious. Minor bleeds post-op that did not attend A&E would not be accounted for in this study, but this simply means that the severity is self-defining. Hence, this should not affect our study unduly. In this study, only the patients presenting with post-op haemorrhage were looked into, there was no control group of non-bleeders to compare. Also, due to lack of data of non-bleeders, we could not perform logistic regression analysis of various probable confounding factors in bleeders versus non-bleeders. Nevertheless, our study result is contradicting to most studies in literature. This is the highlight of our study, and our aim is to bring this into notice that tonsillectomy in OSA group of patients may not necessarily be associated with least complications. There is a growing trend in the diagnosis and recognition of sleep apnoea, which is one reason for more of these patients being operated for adenotonsillectomy. Also, we believe coding of procedures is now strict and probably more appropriate than in the past due to introduction of payment by results. This may be a significant factor for recognition of increasing number of OSA patients presenting with post-operative bleed. Also, restrictions in performing procedures with least clinical priority have probably influenced in reduction of number of tonsillectomy for tonsillitis. We cannot comment on the reason why OSA patients present with bleeding more often than recurrent tonsillitis, and this difference is open to debate. This could possibly be related to fewer exposures to infection in this population and less immunity to the common pathogens, making the children more susceptible to post-op infections and bleeding as compared to the children with recurrent tonsillitis. However, there is not enough evidence in literature to support infection as the cause for secondary haemorrhage. There is also a probability of lower pain threshold in OSA group of patients due to lack of exposure to frequent sore throats as compared to the tonsillitis group. This could lead to lower post-op oral intake and make them more susceptible to bleeds. 6. Conclusion The method of dissection is not the only risk factor for secondary bleed rates. This study has shown significant correlation of operative indication with post-operative secondary haemorrhage. OSA patients are more likely to present with secondary haemorrhage than tonsillitis patients. We invite researchers to
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attempt to replicate and generalise these findings in a range of settings. Acknowledgements Prof M.P. Haggard – Thank you for helpful comments in first few drafts of paper. Steven Lane – Clinical statistician, Liverpool University. References [1] N.J. Ali, D.J. Pitson, J.R. Stradling, Snoring, sleep disturbance, and behaviour in 4–5 year olds, Arch. Dis. Child. 68 (1993) 360–366. [2] R.M. Rosenfeld, R.P. Green, Tonsillectomy and adenotonsillectomy: changing trends, Ann. Otol. Rhinol. Laryngol. 99 (1990) 187–191. [3] N. Tate, Deaths from tonsillectomy, Lancet (1963) 1090–1091. [4] I. Amir, A. Belloso, S.J. Broomfield, P. Morar, Return to theatre in secondary posttonsillectomy haemorrhage: a comparison of coblation and dissection techniques, Eur. Arch. Otorhinolaryngol. 269 (February (2)) (2012) 667–671. [5] F. Javed, M. Sadri, J. Uddin, S. Mortimore, D. Parker, A completed audit cycle on post-tonsillectomy haemorrhage rate: coblation versus standard tonsillectomy, Acta Otolaryngol. 127 (March (3)) (2007) 300–304. [6] G. Mowatt, J.A. Cook, C. Fraser, W.S. McKerrow, J.M. Burr, Systematic review of the safety of electrosurgery for tonsillectomy, Clin. Otolaryngol. 31 (April (2)) (2006) 95–102. [7] S. Maini, E. Waine, K. Evans, Increased post-tonsillectomy secondary haemorrhage with disposable instruments: an audit cycle, Clin. Otolaryngol. Allied Sci. 27 (June (3)) (2002) 175–178. [8] K.W. Chang, Randomised controlled trail of coblation versus electro cautery, Otolaryngol. Head Neck Surg. 132 (2005) 273–280. [9] Clinical Effectiveness Unit, National Prospective Tonsillectomy Audit: Final Report, 2005 http://www.rcseng.ac.uk/publications/docs/national_prospective/ Audit.pdf (accessed 06.02.14). [10] J. Peterson, J.D. Losek, Post tonsillectomy hemorrhage and paediatric emergency care, Clin. Pediatr. 43 (2004) 445–448.
[11] J.C. Stephens, C. Georgalas, M. Kyi, K. Ghufoor, Is bacterial colonisation of the tonsillar fossa a factor in post-tonsillectomy haemorrhage? J. Laryngol. Otol. 122 (April (4)) (2008) 383–387. [12] R. Kumar, Secondary haemorrhage following tonsillectomy/adenoidectomy, J. Laryngol. Otol. 98 (10) (1984) 97–98. [13] F. Ahsan, H. Rashid, C. Eng, D.M. Bennett, K.W. Ah-See, Is secondary haemorrhage after tonsillectomy in adults an infective condition? Objective measures of infection in a prospective cohort, Clin. Otol. 32 (1) (2007) 24–27. [14] J. Windfuhr, M. Seehafer, Classification of haemorrhage following tonsillectomy, J. Laryngol. Otol. 115 (6) (2001) 457–461. [15] J.N. Perkins, C. Liang, D. Gao, L. Schultz, N.R. Friedman, Risk of post-tonsillectomy haemorrhage by clinical diagnosis, Laryngoscope 122 (2012) 2311–2315. [16] R.C. Akin, R. Holst, L.P. Schousboe, Risk factors for post-tonsillectomy haemorrhage, Acta Oto-Laryngol. 132 (2012) 773–777. [17] R.H. Temple, M.S. Timms, Paediatric coblation tonsillectomy, Int. J. Paediatr. Otolaryngol. 61 (2001) 195–198. [18] M.S. Timms, R.H. Temple, Coblation tonsillectomy: a double blind randomised controlled study, J. Laryngol. Otol. 116 (2002) 450–452. [19] A. Belloso, M.S. Timms, Coblation tonsillectomy versus dissection tonsillectomy: postoperative haemorrhage, Laryngoscope 113 (2003) 2010–2013. [20] V. Divi, M. Benninger, Prospective tonsillectomy bleed: coblation versus non coblation, Laryngoscope 115 (2005) 31–33. [21] M. Dhiwakar, W.A. Clement, M. Supriya, W.S. McKerrow, Antibiotics to reduce post-tonsillectomy morbidity, Cochrane Database Syst. Rev. 7 (7) (2010), CD005607. [22] B.J. O’Reilly, S. Black, J. Fernandes, J. Panesar, Is the routine use of antibiotics justified in adult tonsillectomy? J. Laryngol. Otol. 117 (5) (2003) 382–385. [23] W.C. Lee, M.C. Duignan, R.M. Walsh, J.R. McRae-Moore, An audit of prophylactic antibiotic treatment following tonsillectomy in children, J. Laryngol. Otol. 110 (1996) 357–359. [24] A. Tomkinson, W. Harrison, D. Owens, S. Harris, V. McClure, M. Temple, Risk factors for postoperative hemorrhage following tonsillectomy, Laryngoscope 121 (February (2)) (2011) 279–288. [25] J.P. Windfuhr, Y.S. Chen, Hemorrhage following pediatric tonsillectomy before puberty, Int. J. Pediatr. Otorhinolaryngol. 58 (May (3)) (2001) 197–204. [26] R. Ikoma, S. Sakane, K. Niwa, S. Kanetaka, T. Kawano, N. Oridate, Risk factors for post-tonsillectomy haemorrhage, Auris Nasus Larynx 41 (2014) 376–379.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Does primary indication for tonsillectomy influence post-tonsillectomy haemorrhage rates in children? P. Achar *, R.K. Sharma, S. De, A.J. Donne Alder Hey Children’s Hospital, Eaton Road, Liverpool L12 2AP, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 October 2014 Received in revised form 14 December 2014 Accepted 15 December 2014 Available online 23 December 2014
Introduction: A significant risk in tonsillectomy that causes concern to surgeon and patient is posttonsillectomy bleed. Secondary haemorrhage is mainly post-operative bleed presenting at or 24 h after surgery. Classical teaching indicates infection as the cause. There are not enough published data to evaluate the post-tonsillectomy bleed rates in patients operated for obstructive sleep apnoea versus recurrent tonsillitis. We suspected secondary bleed rates to be higher in patients with recurrent tonsillitis. Methods: A retrospective review of case-notes of patients presenting to Accident & Emergency department within 4 weeks of tonsillectomy or adeno-tonsillectomy was performed. 568 patients presented with post-operative complications over the 5-year period 2008–2013. Of these, 222 presented with post-operative secondary bleed. Electronic case records were used to identify indication of operation and matched with coding data. These coded data were also used to identify number of operations and primary indications over the 5-year period. Results: The proportion of OSA patients receiving tonsillectomy or adenotonsillectomy surgery increased over the 5-year period. Secondary haemorrhage rate for recurrent tonsillitis surgery was around 4.9% and for OSA surgery was around 15.6%. Comparison of recurrent tonsillitis against OSA for post-operative bleed showed a relative risk of 0.31 (CI 0.24–0.41). The incidence of bleeding mirrored primary indication for each year. Conclusion: The bleed rate for OSA was unexpectedly higher than for recurrent tonsillitis. The primary indication for tonsillectomy affects secondary bleeding rate. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Secondary haemorrhage Paediatric tonsillectomy Indications for tonsillectomy
1. Introduction The ENT UK position paper (2009) on Indications for tonsillectomy showed a decline in the total number of tonsillectomies over the last few decades. This is one of the commonest operations performed in children. However, there is a rise in the recognition of obstructive sleep apnoea (OSA) and sleep disordered breathing in children and subsequent rise in adeno-tonsillectomy for this indication [1,2]. Haemorrhage is one of the most common complication following tonsillectomy [3] and the most significant one. Several studies have reported correlation of post-tonsillectomy bleed rates in children versus the dissection approach and use of various instruments [4–9]. But there are not many studies looking into correlation of secondary post tonsillectomy haemorrhage and
* Corresponding author at: Holme Avenue, Wigan WN1 2EH, United Kingdom. Tel.: +44 1942820430. E-mail address: [email protected] (P. Achar). http://dx.doi.org/10.1016/j.ijporl.2014.12.022 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
the primary indication for the tonsillectomy. Secondary haemorrhage is defined as haemorrhage following 24 h of injury or operation [9] and is postulated to be due to infection perioperatively [10–13]. We hypothesized that children operated on for recurrent tonsillitis are more prone to infections and hence more likely to present with secondary haemorrhage. To investigate this, we performed a case note review on all patients presenting to Accident & Emergency (A&E) with secondary bleed in a paediatric tertiary referral unit in the North-West of England. 2. Methods A retrospective baseline audit of all patients presenting to A&E within 4 weeks of tonsillectomy and adeno-tonsillectomy between January 2008 and December 2012 was performed. This audit was registered with the Trust audit department. A&E notes of all these patients were screened to identify those who presented with secondary haemorrhage. ENT clinic letters of patients presenting with post-op bleeding were read closely to identify the primary
P. Achar et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 246–250
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indication and any co-morbidities. Standard hospital coded data were used to identify the total number of operations (tonsillectomy and adenotonsillectomy) performed in the same time period and the primary indication for the operation. These count data enabled calculation of the incidence of post-operative secondary bleed in children operated for primary indication of recurrent tonsillitis and likewise for OSA. Incidences were converted to relative risks (RR). 3. Results 3527 tonsillectomies and adeno-tonsillectomies were performed over the 5-year period between January 2008 and December 2012. Of these 417 (12%) were operated for obstructive sleep apnoea and 3079 (87%) were operated for recurrent tonsillitis. 31 (1%) were operated for other reasons. In this department there has been a decline in the total number of tonsillectomies over the last decade, however there is a slow rise in the number, hence the proportion, of cases operated on for obstructive sleep apnoea (Fig. 1). These data do not distinguish between case incidence and tendency to operate as explanation. 568 (16%) patients presented to our A&E with post-operative complications within the first 4 weeks. Of these, 222 (6%) were for secondary bleed, presenting between 2 and 27 days post-op. The median day of presentation with post-op bleed was on day 7. The remaining 346 cases presented in A&E for various reasons which include inadequate pain relief with poor oral intake; fever; and nausea and/or vomiting. The chief primary indication of the 222 post-op bleed presentations was 150 recurrent tonsillitis (150), with 65 OSA and 7 other (choking on food due to large tonsils, halitosis, asymmetrical tonsils for diagnosis) (Fig. 2). In the OSA group of patients, 28 were pure OSA with no history of tonsillitis or sore throats and 37 had OSA with a few episodes of tonsillitis (not fulfilling SIGN guidelines; the primary indication was therefore OSA). The median age of post-op bleed patients operated on for OSA was 5 years and 1 month and modal distribution showed highest bleed rates among 4–5 year olds (Fig. 3). Age of post-op bleed patients operated for OSA ranged from 1 year 1 month to 15 years. In the group of patients operated for recurrent tonsillitis, the median age was 10 year and 7 months and the age ranged from 2 years and 2 months to 16 years and 5 months. There was a bimodal distribution of age of patients presenting with post-op bleed in the tonsillitis group, with peaks at 6–7 year and in teenage years (Fig. 4). Comparing the mean age for the two groups, the OSA group of children (mean = 5.5 years) was almost half the mean age of the post-tonsillectomy group (mean = 9.7 years) and this difference was statistically significant (P = 0.02). The female-to-male ratio in post-operative bleed in OSA group of patients was 22:43 and in recurrent tonsillitis group of patients was 91:49. We subdivided our bleeds through 3 grades
Fig. 1. Annual caseload statistics over 5 year.
Fig. 2. Primary indication for operation in patients presenting with post-operative bleeding.
equivalent to Windfuhr and Seehafer’s [14] classification of post-op bleed severity; grade I = mild oral bleed, not requiring treatment; grade II = moderate oral bleed needing some topical treatment (for e.g. hydrogen peroxide gargles/adrenaline swab
Fig. 3. Age of patients presenting with post-op bleeds in OSA group.
Fig. 4. Age of patients presenting with post op bleeds in tonsillitis group.
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P. Achar et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 246–250
Fig. 5. Severity of post-operative bleed in recurrent tonsillitis versus OSA.
Fig. 7. Annual secondary post-operative bleed rate in patients operated on for tonsillitis.
application to stop the bleed); grade III = significant bleed needing return to theatre for arrest of bleed and/or needing blood transfusions to replace acute blood loss. Fig. 5 shows the break down of the children under each indication for mild, moderate and severe bleeds. Given that we perform an average of 12% of operations for OSA, a significant proportion of OSA patients presented with mild, moderate and severe bleed as compared to tonsillitis group. None of our patients needed ligation of external carotid artery (grade IV) and there were no post-op bleed related deaths (grade V) during the study period.
On comparing annual haemorrhage rate over the 5-year period for OSA and recurrent tonsillitis, we found the haemorrhage rate for OSA was consistently higher than for tonsillitis group of patients. The 5-year cumulative bleed rate for OSA was 15.6% as compared to 4.9% for tonsillitis. OSA patients presented with bleed more often than tonsillitis patients, consistently every year (Figs. 7 and 8). We calculated the relative risk to compare the probability of bleeds in tonsillitis versus OSA. Tonsillitis patients were 69% less at risk. The confidence interval (0.24, 0.41) excludes 1.0, which remains under 1 in both extremes suggesting significance (P < 0.05).
If we now exclude all those patients in the OSA group who had only very few episodes of tonsillitis, we have 28 patients who were operated for pure OSA who presented with post-op bleed. The annual haemorrhage rate in pure OSA was again consistently higher than for tonsillitis group, except in 2012. The 5-year cumulative bleed rate in pure OSA group was 7.4% (Fig. 6). A relative risk calculation showed that the OSA group are 1.51 times more likely to present with bleed as compared to the tonsillitis group. The confidence interval for this relative risk is (1.08, 2.12). This does not contain 1.00 so is statistically significant (P < 0.05). We also looked at the operative techniques used in Alder Hey. The tonsillectomy technique is mainly surgeon dependent and includes: cold steel dissection with ties and bipolar diathermy for haemostasis; coblation dissection and haemostasis; and bipolar dissection with ties and bipolar diathermy for haemostasis. Looking at the OSA group who presented with secondary bleeds, 24% had cold steel, 45% had coblation and 23% had bipolar dissection. Clearly, again, taking into consideration the fact that 12% of patients were operated for OSA, the bleed rates for OSA group of patients was consistently higher for each operative technique. We do not have the total number of patients operated on by each technique over the 5-year period, hence could not perform an interaction test between the indication and technique to look for any statistical significance for the above statement.
Fig. 6. Annual secondary post-operative bleed rate in patients operated on for OSA.
Fig. 8. Annual secondary post-operative bleed rate in patients operated on for OSA and had few episodes of tonsillitis.
3.1. Annual haemorrhage rate over 5-year period
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4. Discussion The national prospective tonsillectomy audit [9] has summarised that the risk of haemorrhage increases with age and also it is higher with hot surgical techniques (diathermy & coblation tools) as compared to cold steel dissection and use of ties. The national audit has also looked into the primary indication of operation and its associated risk, and shown that post-op bleed rate is lower in cases operated for pharyngeal obstruction as compared to recurrent tonsillitis. However there is no data given on the age group of this population presenting with pharyngeal obstruction. Also, in the national audit, only patients registered and consenting to participate in this audit were considered. Hence, there could be a group of patients who presented with postoperative bleed and not recorded in this audit, which can alter the study result. In our study, we included all children who presented with post-op bleed to the hospital accident and emergency department. Re-attenders to A&E can be a selective population excluding all those who had minor bleeds at home that settled spontaneously (this group of patients should not have an impact on our results, as the bleed was probably self-limiting, hence the nonattendance); and those who might have presented to other hospital A&E. Alder Hey Children’s hospital is a major tertiary referral unit in the North West region in England, and we receive children with post-tonsillectomy bleed from other accident and emergency units within the region for further management. This is irrespective of where the child received the first operation. On this basis, it is highly unlikely that any significant proportion of children operated in Alder Hey and presenting with bleed would be missed from our sample. A recent study by Perkins et al. [15] looking into the risk of posttonsillectomy haemorrhage by clinical diagnosis has shown increased incidence of haemorrhage in tonsillitis group of patients as compared to OSA. This study has included incidence of both primary and secondary haemorrhage. There is a possible confounding factor of ease of surgical technique in OSA group with less surgical trauma increasing likelihood of primary haemorrhage in the technically more traumatic surgery for the tonsillitis group due to scarring. It is believed that OSA patients have increased antifibrinolytic state, which could be protective from post op bleeds in this group of patients. Akin et al. [16] however, postulated a slight higher incidence of post-op bleed in their sleep apnoea group of patients as being related to their age. This was again a mixed population including children and young adults. There have been several other independent case series and randomised trials [17–20] looking into the correlation of tonsillectomy technique and post-op bleed rates. Other studies have looked into correlation of post-operative prophylactic antibiotics and secondary haemorrhage rate [21–23] finding no particular use of antibiotics in preventing post-op secondary haemorrhage. The Cochrane review by Dhiwaker et al. [21] has concluded that there is no evidence to suggest a role of antibiotics in reducing post-tonsillectomy morbidity. Obstructive sleep apnoea and sleep disordered breathing are conditions that are being increasingly recognised in the relatively younger population. In Alder Hey, we have seen a steady rise in this subgroup of children being offered tonsillectomy/adeno-tonsillectomy to improve the oro-nasal airway in the last decade. The diagnosis of OSA is done on clinical grounds and overnight pulseoxymetry results. The post-operative care pathway for these patients is similar to the ones operated on for recurrent tonsillitis except for the patients with severe obstructive sleep apnoea who are monitored overnight in the high-dependency unit or in the ENT unit with one-to-two nursing. These children are administered oxygen by face-mask overnight if desaturations are not selfcorrecting and CPAP is available if necessary. Their stay may be
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prolonged by one or two nights depending on the recovery period, awaiting oxygen free night sleeps. Whether this difference in the post-operative care pathway has any correlation with our finding of increased post-operative bleed in OSA group of patients is not clear. Considering the patient demographics, the group of children operated on for OSA is younger than those operated on for recurrent tonsillitis, as expected. Previous studies have shown that older children are more likely to present with secondary haemorrhage than younger children [24–26]. In our study, we have seen younger children presenting with secondary bleeds. 5. Limitations Our study is a retrospective one, setting limitations in the data variables available and in the limited means of controlling for confounders. We have sampled only those patients who presented in A&E in our hospital despite the initial catchment area being wider. There may be some patients who presented with post-op bleeds at other A&E departments and hence not in our records. This population mobility is likely to be small and at random, and hence not bearing a true impact on our results. It is more likely that the patients from far away would have the OSA indication, as Alder Hey is the tertiary referral centre for surgical management of OSA. This would make the differences even more obvious. Minor bleeds post-op that did not attend A&E would not be accounted for in this study, but this simply means that the severity is self-defining. Hence, this should not affect our study unduly. In this study, only the patients presenting with post-op haemorrhage were looked into, there was no control group of non-bleeders to compare. Also, due to lack of data of non-bleeders, we could not perform logistic regression analysis of various probable confounding factors in bleeders versus non-bleeders. Nevertheless, our study result is contradicting to most studies in literature. This is the highlight of our study, and our aim is to bring this into notice that tonsillectomy in OSA group of patients may not necessarily be associated with least complications. There is a growing trend in the diagnosis and recognition of sleep apnoea, which is one reason for more of these patients being operated for adenotonsillectomy. Also, we believe coding of procedures is now strict and probably more appropriate than in the past due to introduction of payment by results. This may be a significant factor for recognition of increasing number of OSA patients presenting with post-operative bleed. Also, restrictions in performing procedures with least clinical priority have probably influenced in reduction of number of tonsillectomy for tonsillitis. We cannot comment on the reason why OSA patients present with bleeding more often than recurrent tonsillitis, and this difference is open to debate. This could possibly be related to fewer exposures to infection in this population and less immunity to the common pathogens, making the children more susceptible to post-op infections and bleeding as compared to the children with recurrent tonsillitis. However, there is not enough evidence in literature to support infection as the cause for secondary haemorrhage. There is also a probability of lower pain threshold in OSA group of patients due to lack of exposure to frequent sore throats as compared to the tonsillitis group. This could lead to lower post-op oral intake and make them more susceptible to bleeds. 6. Conclusion The method of dissection is not the only risk factor for secondary bleed rates. This study has shown significant correlation of operative indication with post-operative secondary haemorrhage. OSA patients are more likely to present with secondary haemorrhage than tonsillitis patients. We invite researchers to
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